Clinical Decision Support Tools in the Dosing of Both Warfarin and NOACs

Part 3 in a 5 part series - Improving the Quality of Chronic Oral Anticoagulation with Evidence-Based Guidelines

In my view, one of the most important ways to achieve optimum warfarin control is the use of an anticoagulation, electronic clinical decision support tool that incorporates a validated warfarin dosing nomogram. We’ve also learned in the last 20 years how we can really move the needle with respect to improving the quality of care for patients on NOACs. Managing patients on NOACs is also a critical component of anticoagulation electronic decision support.

Evidence-based anti-thrombotic practice guidelines published by The American College of Chest Physicians include recommendations for the management of patients on oral anticoagulants and highlights the importance of systematic and coordinated care within an anticoagulant management system. For the longest time there have been dedicated Coumadin clinics that performed this function. However, the question is how well are we performing across the country and across diverse clinical settings?

What we have also learned in the last 10 years or so, is that we will definitely improve the quality metrics of Coumadin dosing by using a validated dosing nomogram, as opposed to using intuitive dosing as we have been used to doing for a long time. The only validated dosing nomogram that that has been validated in a prospective, randomized trial is the Hamilton Dosing Nomogram.

Hamilton Nomogram

This nomogram uses the current weekly dosing schedule measured in milligrams, and based on the newly obtained INR, it has an algorithm to depict a new weekly dosing schedule for patients. Using this nomogram, in a prospective trial, we were able to achieve TTRs in the 72% range which really represents excellent warfarin control.

However, it’s not enough just to have a warfarin dosing nomogram. And it’s really not enough to just have trained personnel. I think one of the most important advances that we have seen in the last 7-8 years, as we approached the new era in electronic health records, is the use of these EHR tools that can help us deliver optimized anticoagulant care.

I was very proud to chair a multi-institutional and multi-disciplinary consensus of the EHR Task Force at the New York State Anticoagulation Coalition. We brought together multiple providers who were very experienced in chronic oral anticoagulant management. The consensus group identified 78 key features of an EHR that can really advance chronic oral anticoagulant care.

EHR Task Force

In part 4 of this series, we will do an overview of EHR key features necessary for delivering optimized AC therapy.

We would like to hear about your experience with using EHRs to deliver comprehensive anticoagulation management for your patients. What has worked? What has not worked so well? What features or decision support tools in your EHR would improve your ability to deliver high quality, safe and efficient AC care?

Topics: Anticoagulation, Hamilton Nomogram, Validated Survey Instruments, Warfarin, Adverse Drug Events, Clinical Workflow, NOAC, TTR